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Transforming Hip Surgery from 2D to 3D: Insights on Anterior Approach and Advanced Tools 🦾👨‍⚕️

• Anterior Hip Foundation • Season 2 • Episode 20

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Transforming Hip Surgery from 2D to 3D: Insights on Anterior Approach and Advanced Tools 🦾👨‍⚕️

In this episode of the AHF Podcast, host Joe Schwab discusses the revolution in anterior approach total hip replacement surgery with Dr. George Haidukewych from Orlando Health and Dr. Brad Waddell from the Carrell Clinic. The conversation explores the impact of 2D and 3D preoperative planning tools on shaping implant choices, enhancing accuracy in complex cases, and guiding intraoperative execution. Key technologies discussed include Smith+Nephew's CORIOGRAPHâ—Š pre-op planning, RI.Hip Solutions, CATALYSTEMâ—Š primary hip system, and the CORIâ—Š Surgical System. This episode highlights how precise planning and cutting-edge tools contribute to better patient outcomes and streamlined surgical procedures. 

This episode is sponsored by Smith+Nephew. Learn more at smith-nephew.com

Joseph M. Schwab:

Hello and welcome again to the AHF Podcast. I'm your host, Joe Schwab. Today we're joined by two leaders in hip replacement surgery, Dr. George Haidukewych from Orlando Health, and Dr. Brad Waddell from the Carrell Clinic. We'll discuss how preoperative planning with 2D and 3D tools is transforming anterior approach. It's shaping implant choices, improving accuracy in complex cases, and guiding intraoperative execution. Whether you're experienced in hip arthroplasty or just getting started, you'll find valuable insights in this conversation. Dr. Haidukewych, Dr. Waddell, thank you for joining us today. before we dive into the technical details, how did each of you come to adopt anterior approach in your practice? What sparked your interest in the technique?

George Haidukewych:

I've done all the approaches over the last 30 years and over the last five have. Move to almost all direct anterior for several reasons. First and foremost, just looking at the data of how well patients recover. I think it's really a patient driven, they want the approach, they want to get back to activities the patients are operating on are younger, they're more active, and I think we've solved the problem of long-term durability. And implants. Let's face it, our uns cemented modern implants can last decades and decades. We're not really worried about loosening. We're less worried about poly wear. so what's left? can we get the patients back sooner? Can they get more active? Can we be less invasive in our approach? Can we. Have them get rid of their gate aids quicker, even go home the same day. So all of that kind of came together at the same time. The drive to outpatient surgery, patients being younger, patients wanting to get home quicker, get back to things, and then people talk. They want, my neighbor had a DA hip, he was back golfing in two weeks. you're, if you don't do that approach, you're gonna have a hard time competing with that. So that all of that kind of came together at the same time for me.

Joseph M. Schwab:

Dr. Waddell, how about you?

Brad Waddell:

Yeah, so I, I'm in my 10th year of practice, so I was fortunate to train in the era of where anterior hip was coming about. during my residency, I never saw an anterior hip. I came into fellowship saying, I'm just gonna learn how to do some of this, and I'll go back to what I know, what I've seen. I recall the clinic where I watched a patient at two weeks follow up and they just talked about how amazing they waltzed down the hall. They were moving their hip in ways that I'd never seen any hip do at any time point. And so I distinctly recall the moment where I said, man, I'm gonna lean into this. So I was very fortunate to train under some really good surgeons who taught me anterior approach. Since then, it's been my go-to approach for the last 10 years.

Joseph M. Schwab:

What were some of the big challenges that you both faced doing anterior approach early on?

George Haidukewych:

I think the, just being familiar with the anatomy, 90 degrees to the way you're used to looking at everything, and the, learning the exposures. I think that whole operation, to be honest with you, is about careful soft tissue handling and excellent exposure. Really the reaming broaching is the same as you do in any other hip. But being able to see and not damage the TFL and other soft tissue structures in and out of the hip, carefully delivering the femur, there's a learning curve to that. you don't wanna start with a BMI 60 with a broken nail on their femur. You wanna start with somebody skinny, easy, and then gradually learn from, several surgeons. The exposure moves.'cause once you have the exposure down and it becomes a pretty straightforward operation. But that was the biggest hurdle, is just to learn these moves and the sequence of, okay, what do I do if I can't see the as tabular wall? What's my checklist? What do I do if I've done all the releases, the femur is still not coming up, what do I do? So getting through that and doing this when an experienced surgeon, I think is critical.

Brad Waddell:

Yeah, I couldn't agree more. I, definitely learned tips and tricks and pearls in, fellowship where I got to skip some of the learning curve. But I also suffered from having watched some of the best surgeons. Did the world do it? And, jumping right in, I was experiencing things that, I didn't see them go through. absolutely. I think, soft tissue exposure, ch making sure everything's in the right place. There's no question, there's a learning curve to it. even now, I don't do very many posterior approaches, primaries, but it can just come right back to you. The anterior, thousands later, I still will have times where I struggle more with an anterior that I've done many more times than a posterior. I, I think soft tissue exposure and then proper releases, can really set the case apart.

Joseph M. Schwab:

So let's talk a little bit about your pre-op planning.'cause I get the impression from hearing both of you talk that precise pre-op planning is something critical for a successful anterior approach. Are there particular patient or anatomy factors that, you take into account during the planning phase or make planning sort of non-negotiable for you? Tell me a little bit about that process.

George Haidukewych:

Yeah, I think, I get sitting and standing views of the pelvis, lateral views to look at the lumbar, mobility and the pelvic tilt. I think that's become routine in my practice. Every new patient gets those x-rays and you'd be surprised at how much that can affect your impingement arc if you actually model it. And some of the, the CORIOGRAPH software that I use. Basically automates for me. I don't have to get the protractor out and start writing all sorts of angles. We enter the pictures and it'll do an impingement analysis for the case. So if you think about it, you're trialing before you even open the patient, you know you're gonna need a size F, a size 52 cup, whatever, five, high offset, zero ball, here's your neck cut, here's your hip center. So it gives you the position of the components. That will not impinge taking into effect, into, account rather the lumbar tilt and the pelvic deformity, if any. So it does the math for you, which is nice. I simply ask my rep, what's the target? They said 42 17, whatever it is. That's my impingement free arc and it's a size 5 54. that's saves me a lot of time in surgery because, if all of you are on table surgeons. Multiple trials are a pain in the neck on a DA approach. You gotta take everything out, put everything back. It's not a quick, just popping your head on, it's laborious. And if you're changing offset, changing leg length, changing, version what have you doing that ahead of time to know you'll be impingement free. Really saves me a lot of time. It's also pretty tough on a table to check for posterior in stability. I don't think any of us are taking the boot out, flexing the hip to a hundred degrees and internally rotating and contaminating the whole feed. I've never seen anybody do it. so checking for posterior stability, again, impingement, you could do that ahead of time with the CORIOGRAPH software. So I love it. It's become routine for me in my practice. I do it on every patient.

Brad Waddell:

Yeah. So to that point, you ask about pre-op, it's, non-negotiable. There is a significant amount of pre-op templating and planning that goes into every case. As George said, it's gotten a whole lot easier. it's always been, x-rays 2D slap on, the cellophane thing and make sure the sizing is right, but in terms of where we should be putting it. As opposed to just the size has gotten, a lot easier and a lot better. It began with Smith+Nephew's modeler, where they were the first ones to actually model implant impingement, and now we've jumped forward to 3D modeling, including bony impingement, et cetera. It's just made life a whole lot easier. like George said, taking all of this into account prior to even putting any, prior to touching a patient is, life altering for me. I, feel the same way. Me and my rep, the engineers on the CORIOGRAPH 3D modeling prepared for us based on my preferences in a meeting you have with them. But then, once I have the engineer's plans, me and my rep will go over before the day, before cases. We'll look at all of those, templates, models, and make appropriate changes prior to getting into the operating room. As George said, I've already taken the patient through all of these tests, and, it, certainly has made life a whole lot easier. I've found myself trialing less and, cases are going faster and smoother.

Joseph M. Schwab:

So does every patient get both two dimensional and three dimensional planning or do you decide between the two and how do you decide which one you're gonna do?

Brad Waddell:

For, three dimensional. It requires a CT scan. about 35% of my patients come from out of town, so we haven't done it for those patients, but I want three dimensional on every single person. and we're working on ways to, expedite, right now it's about the quickest turnaround you can get on 3D templating, which is less than two weeks, but understandably, patients don't wanna fly in town or drive in to get it. And so with my practice, we're working on getting 3D for everyone, but I'll tell you, the benefits of 3D templating, including the femoral version, where the neck cuts should be, taking femoral version into account. certainly, over the last 10 years, I've only had to change the cup a few times. maybe 5, 6, 7 times. After I put the stem in because of a version that I wasn't expecting, and we have the ability to eliminate that step, once a year, once every other year. But still, those are sticking points that I remember. Every one of those cups I've had to change after putting the stem in. So certainly 3D templating is a very nice way to go. And the benefits of it include that Fal version.

Joseph M. Schwab:

George, how about.

George Haidukewych:

Yeah, I think said. The I use the 3D selectively. Probably 25, 30% of my patients I'll send for the 3D planning when I'm worried about boney impingement or like he mentioned, femoral version weirdness or some sort of deformity. I've had a few femoral deformity cases where I wasn't sure whether I could sneak down like a primary catalyst stem, and sure enough, they did the 3D and if. I thought for sure I'd need an osteotomy. So something unusual in the anatomy. They all get three D's routine. Grandma with a simple arthritic hip, normal version. Normal anatomy looks great. I'll just do the 2D planning and I found that to be accurate. It's faster and you could get that very quickly. I.

Joseph M. Schwab:

Have you found any differences in how you view or assess or think about things like leg length or spinal pelvic balance based on whether you're doing 2D or 3D?

George Haidukewych:

it takes the, the software, 2D or 3D will tell you your effect, if you put into templated sizes on leg length and offset, which is nice because let's face it, we've seen these males that have these giant long femoral necks, huge amount of offset. And we're worried how are, we're gonna restore tension on those. And, there, with the 3D planning, you can actually move the cup and maybe not media, alize all the way to Kohler's line to try to get some offset there. You could change your neck cuts and play with different STEM geometries. It's really very useful. So it gives you, i, I call it like templating five oh one. It gives you just a different view of the hip in three dimensions where you put the hip center and how you handle femoral deformity. So it's been, as far as do I view the hip differently? Yes, I think I understand it at a deeper level now that I can actually move things in three dimensions. It's very interesting to do. It's great to teach, if you're teaching residents and fellows, it's a great tool to help them think about hip center and offset.

Joseph M. Schwab:

Brad, does having these tools, impact your, having these tools at your disposal? Does it impact your confidence heading into surgery or are you confident either way.

Brad Waddell:

No. I'm a very nervous person and there is a controlled confidence that's been there and it control, it continues to get more and more. certainly on three DI find that leg length estimation is more accurate. I like that aspect of it. the, to George's point in terms of teaching, it's a wonderful tool, but I'll tell you, I think I've probably, Learned more myself than I've been able to teach. I'm a mentee of chit ronaut who combined aversion is 45 degrees. But I, think that combined aversion of 45 degrees is a posterior approach. Specific combined verion. And what I've found using CORIOGRAPH, using 3D Templating is that my combined inversion is in the low thirties. and I've been able to see that and learn more. Again, more about myself. If you talk to me 10 years ago, first year in practice, I was shooting for a combined inversion of 45 degrees in the anterior, and I think that's probably too much. It, has allowed me to, I think, become more confident and certainly I think I've learned more about myself as a surgeon using these, 3D templates because I have so much information in my disposal. it's, it, I think it's gonna continue to make me a better surgeon.

Joseph M. Schwab:

this raises an interesting question. you both described seeing differences in intraoperative adjustments that you might make, either decreasing the number of adjustments you might make, or changing how you would make those adjustments as you've been incorporating this, the sort of extra planning, the two dimensional and three-dimensional planning. Are you seeing differences in outcomes with this extra, with, the, planning methodology that you've been using?

George Haidukewych:

obviously hard to assess. the DA patients do so well. I have a very low rate of instability, so that's, a good thing. but I have no, nothing to compare it to because I've been planning, with this ever since I started. so it'll be it. If you look at the instability rate in DA Hips is about 0.6%, just depending on what study you read, like one to 200 about. So it'll take a massive study, massive amount of patients to prove, but there's no logic that defies. the fact that if we put it implants in accurately and we can avoid impingement and optimize leg length and offset intellectually, they should have a better outcome over the long term than those that where we did not do that. But again, it'll probably take tens of thousands of patients randomized somehow to prove, but why would you not if you couldn't? It is basically the analogy I give our students. It's bill. Building a custom suit for somebody versus giving somebody right off the shelf and put everybody at 40 15 and hope for the best. Now you can actually define the target for that patient specific. Lumbar pathology or their pelvic O liquidity, and you could say, okay, they need 45, 25 to avoid impingement, and then you hit that with the navigation. We'll use the corry navigation to actually hit that target. So if you can be that accurate to define the target for a specific patient and then hit that target now, it just takes time to get enough data to prove that they're doing well.

Brad Waddell:

Yeah, I have a couple of thoughts on that and I couldn't agree more that, anterior hips in my practice and almost everybody's practice do take a lot of people to see a big difference. we're following patient reported outcomes and if we properly tension the muscles and if we properly put the patient, then you know, they're gonna have a, faster return to a forgotten hip score. Or they're going to just, muscularly feel better. I've asked, my neurology friends. Do you think an EMG would show a difference in muscle tension? And we don't have a way to look at that yet, but I think that's where the next steps of this is going to go is we're gonna be able to, see patients where they belong, are gonna lead to patients with better outcomes, faster return to activity, faster, forgetting the hip replacement faster. retrieval studies are super important and when I was a fellow, we did a retrieval study looking at impingement on liners, and large heads decrease dislocation, but we showed that large heads didn't decrease impingement, and so we were seeing deformities on the edge of the cup. that, that were there with a 22, 28, 32, 36. but we, so there was the same level of impingement, but decreasing levels of dislocation because it jumped distance and all that sort of stuff. And so I think, to George's point, as we put things where they belong. In retrieval studies, we may see that impingement is gonna decrease. Certainly there is a consequence to that. Impingement. We don't know exactly what it is. We don't have the ability to test it. But in the macro scale, dislocations are probably gonna be about the same. They're gonna be and maybe lower, 0.3% instead of 0.6%. so hard to tell with, small numbers of patients.

Joseph M. Schwab:

Do you think we'd be able to identify a subset of patients, who are at higher risk for postoperative complications, poor outcomes that would really, truly benefit from this type of technology where you wouldn't need nearly so many to see a substantial benefit, from a research perspective? Have you thought about that?

George Haidukewych:

Yeah, I think, the subgroup that I'd like to study is those with the a fixed posterior pelvic. Tilt. In other words, the aversion is accentuated on, the DA approach. So if you put in your standard fluoro, guided cup, half face open or whatever enabling technology you use, you may have a functional aversion of 30, 35 degrees and you think it's 15, right? So I think, look, looking at a subset of those, fixed pelvic obliquity, cases where the pelvis is stuck in a sitting position. I think that would be, a subset that without careful planning, if you put your standard aversion on, you're gonna be over univer and risk anterior instability. That'd be a fascinating one. And conversely, those with an anterior pelvic tilt, so you will click an inlet view on x-ray. those have a high risk of posterior instability. If you under univert the. So those outliers, I think that would be great to look at that subset to see. we could probably do the study'cause half my partners don't use any, advanced planning and, half of us do to see if there's any difference. But we'd have to go into those high risk groups. But those outliers are actually the ones where this technology helps me the most. Those were, you, if you read some of the, earlier literature, by door and Victor Doic, they'll tell you in some of these cases, okay, add a little aversion or take a little aversion off, depending on the pelvic position. But what does that mean? Add a little verion. How many degrees? These programs, a CORIOGRAPH can actually take that into account and they'll tell you 43 17, they'll give you something that specific, and that's your impingement free position. Then you could hit it with the navigation, you can actually hit 43 17. So it's been, really helpful in my practice.

This episode of the AHF Podcast is brought to you by Smith+Nephew, a global medical technology company focused on helping patients live without limits. Smith+Nephew works across orthopedics, sports, medicine, ENT, and advanced wound management, combining innovation and technology to repair, regenerate, and replace soft and hard tissue. One of their standout offerings is the CORIâ—ŠSurgical System, a flexible and scalable platform with proprietary tools and software for knee and hip arthroplasty procedures. When paired with CORIOGRAPHâ—Špre-op planning and modeling services, RI.Hip Solutions, and the newly launched CATALYSTEMâ—Šprimary hip system Smith+Nephew delivers a complete and cutting edge solution for primary total hip arthroplasty. To learn more about how Smith+Nephew is taking the limits off living, visit smith-nephew.com.

Joseph M. Schwab:

So apart from, the software telling you, for instance, exactly what your target might be for position, are you ever able to, or do you ever encounter a situation where it's gonna change your surgical strategy or even change your implant choice based on. What's, what would be considered implant free? Would you move to a dual mobil, excuse me, impingement free? Would you move to a dual mobility? Would you change your, type of cup or just the position of the cup?

George Haidukewych:

you can actually change that in the program. You can go to do a mobility, go to 36 head 40 head, depending on your cup size, obviously change the offset of the stem. So the cool part on the 3D planning is you could play with all this in real time. It'll tell you immediately when you make that plan. There's, little box that says leg length and offset change. And it simulates activities of daily living, which are great, deep squat, things like that. golf swing, what have you. So it'll tell you whether you're having external rotation or internal rotation, stability, or impingement. It'll show you exactly on the model where the impingement is. Is it bone, is it liner? Is it femoral neck? And then you can add offset. You can add change of bearing, like you mentioned, change of stem, whatever you wanna do to get rid of that impingement. It's an incredibly versatile tool for that.

Brad Waddell:

Yeah, so if we look back 10 or 15 years ago when, dual mobility first came to America in the modular state, it was used when we couldn't figure out what to do. I've found my dual mobility rates have decreased because now I know where to put the parts and, dual mobility is a backup plan when, sure, there's still instances where it's used, but dual mobility is a backup plan for when. You can't figure out the pelvis, you can't figure out, where they sit in space where they're gonna move or not move. I use less dual mobility now because I put the parts in a better position. And to your question earlier, it is the outliers who matter. It's the flat backs and it's the over the Lords who are going to come out the front, flat back, come out the back overly lordotic, and then it's the fused person who doesn't. Excuse me, move sitting to standing. Those are the ones we really worry about. And yeah, we're, actually looking at those now. And, following into that second question, being able to put the parts where they belong decreases the need for a backup plan, like dual mobility.

Joseph M. Schwab:

Yeah. Interesting. So you both, relied on some data, so brought up some research here as far as, the groups that are at risk, what the current benefits are of anterior approach on its own. so one question. Can you share any of the outcome data about 3D planning? Is that out there in the literature yet? And how do you rely on, how do you use that to make your decisions?

George Haidukewych:

There's a little bit of literature out there about. Actually looking at bony impingement, right? Something we really don't think about. We think about implant impingement a lot. I think it's Doug Dennis' series. They looked at, I think they had about a third of their patients actually had some bony impingement when the surgeons were, would put the cup or where they wanted. Basically, they let you do your standard planning and they put your plan, say it's a 40 20, whatever your cup position is into their 3D program, and found that probably a third of the time you'd have an impingement. If you put this cup in your same spot every time, so there is data that impingement modeling and 3D planning will help you identify things that you didn't foresee. There's plenty of data, but it's primarily posterior approach at this point about, The planning and robotic or navigated execution, right? So if you're doing robotic or navigated execution, you have a target. Somebody's told you where to put the cup, you don't just randomly put it in the human being. And that data shows pretty significantly from a posterior approach that it significantly decreases the rate of instability. Having said that the instability rates multiple times higher from the back than the front. Therefore, we're gonna need some pretty big series to show a benefit for the DA approach. I think those will be forthcoming as the approach gets more and more popular.

Joseph M. Schwab:

How do you use this evidence? so George, for instance, you mentioned that half your, partners, use, some sort of, planning technology like this half don't. and how do you share this type of evidence with your colleagues, with your hospital administrators, with your colleagues across the country or around the world? To encourage adoption to talk about, what direction we need to take this in.

George Haidukewych:

Yeah, that's just a matter of education, showing them the benefit. one of the best benefits other than time surgeons are always sensitive to operative time, right? Time is money. Time is more cases, anesthesia, time for the patient. If you don't have to take as many pictures, many of my, partners will use C-Arm to ream and put the cup. They're taking four or five pictures just to try to reproduce a real AP pelvis. That's a lot of radiation if you're doing a couple hundred hips a year, if you're taking extra 5, 6, 7 fluoro shots. So I, the way I've gotten a few of my partners to jump on board is, number one, you get the targets so you know where to put the cup. You could do it all without c-arm completely. I don't use cm to put my cup in at all and, it's looks great. The final pictures when you're done. All said and done. It's exactly what it said. So operative time, less trialing, more accuracy, less radiation. that's an easy sell for, most people.

Joseph M. Schwab:

So, talk to me a little bit, and Brad, maybe you can chime in too. How do you translate the three dimensional plan or even the two dimensional plan? How do you translate that pre-op plan into cut position without using intraoperative imaging? Is it navigation? What, does that look like?

Brad Waddell:

Yeah, it is navigation. experience obviously helps with all of this, but. the Smith+Nephew CORI system is the intraoperative execution of the plan made with CORIOGRAPH. And CORI is the navigation system that allows you to put the parts where you think you're putting'em. Of course, it's an evolving technology that'll continue to get, more in depth, but at present. It's one of the most simple, easy ways to, execute, a hip replacement, that I think is out there. to George's point. and adding to George's point, I don't wear lead. I haven't worn lead in, seven or eight years. and I still remember, my first couple of years of practice changing scrubs multiple times a day'cause I was so wet. From sweat and wearing big, heavy lead. the CORI intraoperative execution allows you to put the parts exactly where you have planned to put'em. And, that's what has led to all this pre-op planning is now, once we had the ability to put the parts where we wanted to put'em, we found out that wasn't perfect and that pushed more for the preoperative plans and the ability to. Individualize this hip replacement surgery for each patient. it's, the, query system has the fastest registration, the lowest cost, all the different things, you could query. We have every robot in our hospital. You can query who the techs who, which one they like to use best. And it's the simple CORI, I've done, I'm getting close to a thousand CORI Hips and, it, it's been seamless from day one. it's been a great, experience.

Joseph M. Schwab:

So you have an intraoperative monitor that, for instance, the acetabular component positioner that you're putting in is it's able to tell you when you've got it in the exact right position. Is that how it works?

Brad Waddell:

to George's point, we're shooting for 43 17, and so I can get it at 43 17. and so being able to plan for 43 17 and then a live feedback. Utilizing the tools that you use on a day-to-day basis, not a giant arm. That's in the way, out of the way, not the way I do a normal hip. it just tacks right onto the parts that I use every single day. Muscle memory is the same, and then I put it in at 43 17. so yeah, it's a seamless way to, to achieve that preoperative plan.

Joseph M. Schwab:

George, if somebody wanted to double check their position with, if they're, say they're moving from a fluoro based system to CORI and they want to double check, so they're getting the visual input that they're used to, but they're also getting the input from the system. Can you bring fluoroscopy in and double check? Is that easy enough to do, or would that be a little more challenging?

George Haidukewych:

No, it's easy. it's CORI's a very small footprint. It's a tiny little unit, so in my cases I actually have Floral and CORI both. I use a fluoro at the end to make sure I'm happy. I, would never leave the or without an x-ray. I think that's ridiculous. But what I'll do is I do four x-rays, four single shots, and in incorporate CORI into this, we, you, when you first start the case, you register the anterior pelvic plane by getting the ASISs. It takes a few minutes. Do your routine exposure. I still check my neck cut under floral to make sure it's not too vertical or too high or what have you. Make. Put a little o osteotome where I wanna make my cut, so I'm happy with that. Then I do the rest of the operation really without x-ray. Put the whole cup in. If for some reason you don't like the way it looks, no problem. That's when I first started doing CORI a few years ago. I didn't believe some of the numbers I was seeing. And you know how the pelvis on the table can sag quite a bit and be pulled with traction. So what you think is. 10 of aversion is really 40 of aversion. You can get really crazy numbers. So I would bring in the floor to check it going, let me see if I trust this thing. And it was right Every single time I, my eye was wrong. the navigation was correct. So I highly encourage you, if you're a fluoro user, try to wean yourself off. It's just, use less and less x-ray, but do single shots to convince yourself. To trust the navigation, but I use both in my or routinely. I check my leg lengths at the end with an x-ray, make sure I like my cup position. My stem looks right down the shooter, so absolutely. I use both in every case.

Joseph M. Schwab:

and George, you're doing this on an orthopedic table, is that right?

George Haidukewych:

Yeah. Yeah. Honda Table. Honda

Joseph M. Schwab:

On the Honda table and Brad, how about you? What are you doing it on? Okay.

Brad Waddell:

I'm on the H table as well. I use x-ray as well. I only take two shots. I get the full cup in the STEM trial in, that's when I take my first shot. And I agree with George. STEM position is always what, again, after 10 years of doing this, I still worry about STEM position. And I think it's something that's just inherent in the anterior approach. To George's point, the pelvis that you see on that standing pre-op film is not the pelvis you're seeing laying on that table. we did a study on that a couple of years ago where we looked at the pubic synthesis gyal distance. And so my partner in the operating room recreates the functional plane and recreating the functional plane is, basically. Getting the, cantor of the x-ray to where their pelvis would be when they're standing up. That's the pelvic tilt. And so y yeah, when you look at something in the operating room and they're laying on the table, you're gonna be wrong in guesstimating in most patients unless they have a neutral pelvic tilt, which most people do not. It's absolutely right that the CORI, navigation is gonna be telling you the correct number based on, most likely their standing film if you're shooting for the functional plane. But those two x-rays are not the same.

Joseph M. Schwab:

George, I'm interested to know, because you mentioned right at the beginning as you you were in practice, you moved to anterior approach and learning and understanding the anatomy and understanding how the anatomy, how the planes work. C 90 degrees opposite from, from what you were used to. Have these intraoperative tools changed your understanding of the surgical approach, or changed the way you've done the surgical approach? Or is it pretty much what you came to, came to learn at the beginning?

George Haidukewych:

It's not that much different approach wise. You have to have good circumferential exposure of the cup. get a couple cobras in there and really see a 360 because, they say garbage in, garbage out. You've gotta get good data points when you register the Ace Tablum. And to do that you gotta get deep. And some of these patients are heavy. It's a long way down. airplane to table away from me'cause I've already registered the anterior pelvic plane so I could tip the patient upward, make it a lot easier to register. Registration of the socket takes about. 20 seconds. If you're, once you've done a few, it's very quick. And then the acetabular fossa, it's very quick. So I think the thing that gets, the only thing I would do different if I wasn't doing that is I don't need as perfect exposure of the acetabular. If you're navigating in my hands. You gotta get good registration. And to get good registration, you gotta have killer exposure of the aceta.

Joseph M. Schwab:

Brad, how about you?

Brad Waddell:

Yeah. To that point, about six, maybe five or six years ago, I was starting to notice that in some cases I felt like I had a lot more anterior acetabulum exposed, and in some cases I felt like I had a lot more posterior. And, in fact we were talking about let's do a study on this and find out why. And now we know some patients are anteriorly tilted, some patients are posteriorly tilted. And it wasn't until I was able to see that before going into the operating room. Then seeing that I'm seeing more here or there. And that should change the way that you ream that cup. And if you're reaming everybody exactly the same, you're blowing out anterior or posterior walls, because some patients are gonna be anteriorly tilted, some patients posteriorly. So I'll say that, this pre-op templating, knowing what the patient. is gonna look like before I even show up in the operating room, has allowed me to answer a silly question that I had 6, 7, 8 years ago, that I couldn't understand. Why, am I seeing so much of this? And now we know it's because they're tilted one way or the other. And, as we said earlier, the ones that are really scary, or the ones that present the most that way are the ones who are fused with no mo mobility at all. And that's why they're gonna present that way, laying down.

Joseph M. Schwab:

Gentlemen, I've really appreciated the, what you've been able to share with us today about the technology that you use. I have a couple of quick follow up questions before we close, and Brad, I'm gonna start with you. I'd like you both to answer this question, but let's have Brad start. If you could give one key piece of advice, to surgeons who wanna improve their anterior approach outcomes, what would you say? Is there a lesson you wish you knew when you started?

Brad Waddell:

I, think it's lessons that I was told I shouldn't. It takes a long time to learn, and that is introduce everything one piece at a time. Go slow. Don't start something new on an eight patient day or an eight case day. and, then at the same time, know that there's a learning curve with anything. Frustration is common and so slow and steady, change one thing in your practice at a time. Don't change your practice during a an insane, busy time. you gotta give yourself the time to adjust and, get to the point where, you become comfortable with it before you start going real fast.

Joseph M. Schwab:

George, how about you?

George Haidukewych:

That'd be two things for DA outcomes. Number one, I, would suggest that you learn from several different surgeons watch their moves on exposure. How do they see the socket? What do they do if it's hard to get the reamer in and out? What are, what's the checklist to get out of trouble? And how do they get the femur out without doing unnecessary releases? When do you need to go to more release and, how do you do this? So I think good exposure tricks are, number one, learn from experienced surgeon. See, several. Then maybe do one with him or her so they can teach you. And then as far as the technology, I agree, like introduce technology a little bit at a time. So you just wanna navigate the cup. Start there, do it in a cadaver. Learn the buttons, the gizmos, and watch an experienced surgeon do it. And many of us have people that visit, they'll watch in the or and we'll go upstairs and do it in a cadaver lab. So you get a great registration and then you'll see it's a very easy, it really, makes the operation slick.

Joseph M. Schwab:

And one final question as you both look ahead. How do you see planning and intraop tools like you've been talking about today, evolving or maybe what excites you most about what's coming up in total hip arthroplasty? George, let's start with you.

George Haidukewych:

Oh, I think handheld robotic execution's gonna be the future. We'll have the plan. The plan will take minutes. Instead of waiting two weeks for an engineer, it'll probably be AI automated that it'll know that this patient has a posterior pelvic tilt. It'll give you the plan. Then you'll have handheld robotics. Instead of bringing in this giant Volkswagen with an arm into the operating room, you'll, it'll be part of your reamer. It'll be part of the tool. It'll help you make a neck cut exactly where you want it. It'll help you put the hip center exactly where you want it. With robotic reaming and execution, I think, and a small footprint. It won't be a giant million dollar unit. It'll be much smaller compact, so you could have multiple rooms in the SUR Center using the devices. So I think that's coming down the pike. It's gonna be very exciting.

Joseph M. Schwab:

Brad, how about you?

Brad Waddell:

Yeah, I couldn't agree more. I think that planning will get, more, both more efficient, but also, more all encompassing. again, there's still stuff we're learning and as we learn what we should be doing and what each patient may need, that's where planning is just gonna get better. Couldn't agree more that having a small footprint relative. I tell people all the time that the reason that F1 fifties are made so fast with robots is'cause every single F-150 is the same. That's why that robot can just do this back and forth, whereas. We can't, we aren't ready for that yet until we can individualize each patient and then have that brought to the or. so for me, being able to augment the tools that you use in a small platform, allows, if it doesn't work, you could just go right to your standard tools. And I think that a small pla platform that augments the tools that we use is the way of the future.

Joseph M. Schwab:

Excellent. I'm looking forward to it. The way you're describing it. It's gonna be exciting to see what's coming down the pike. gentlemen, I want to thank you both for joining me today on the AHF Podcast.

George Haidukewych:

My pleasure.

Brad Waddell:

Thanks for.

Joseph M. Schwab:

Thank you for joining me for this episode of the AHF Podcast. As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content just like this. Please also drop any topic ideas or feedback in the comments below. You can find the AHF podcast on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube slash at anterior hip foundation, all one word. New episodes of the AHF podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips happy, healthy, and well planned.

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Joseph M. Schwab

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